Remaining smokers need aggressive intervention.(CLINICAL ROUNDS)

PHILADELPHIA -- American smokers have, on average, become significantly more nicotine dependent since 1989--which means that more aggressive interventions are needed to help them quit.

That's because most of the smokers who could more easily quit have already done so. "The less-addicted smokers are out of the pool. We're left with people who are more dependent," Dr. David P.L. Sachs said at the annual meeting of the American College of Chest Physicians.

"The vast majority of patients we see now in actual clinical practice are more highly nicotine dependent," said Dr. Sachs, director of the Palo Alto (Calif.) Center for Pulmonary Disease Prevention. Dr. Sachs documented this shift by comparing the average level of nicotine dependence in patients who participated in three smoking-cessation studies that he collaborated on during 1989-2006.

In all three studies, nicotine dependence at baseline was quantified with the Fagerstrom Tolerance Questionnaire (FTQ), a brief, self-report survey that measures nicotine dependence on a scale of 0-10, with 10 being the highest level of dependence (see box).

Among 220 U.S. smokers enrolled in 1989 and 1990 in a study of a nicotine patch, the average FTO score was 6.62. The next study enrolled 206 patients in 1994 in a study of sustained-release bupropion; their average FTQ score was 7.02, significantly higher than in the prior study.

The third study group cited by Dr. Sachs included 2004 patients who were enrolled in 2005-2006 to assess an individualized treatment regimen. These people has an average FTQ score of 7.44, a significant jump above the 1994 average.

Looked at a different way, the percentage of patients rated as highly nicotine dependent, with an FTQ score of 7 or higher, was 56% in 1989-1990, 66% in 1994, and 73% in 2005-2006.